Abstract
Discussion Forum (0)
ePoster
Topic: COVID-19
Kirsch RE1,2, Helmers A1,2, Schwartz S1, Tijssen J3, Yates R4, Moore GP5, Ly L6, Mullen M7, Anderson J2, McCradden M2, Dhanani S8, Gilfoyle E1.
1Department of Critical Care, The Hospital for Sick Children, Toronto, Canada
2Department of Bioethics, The Hospital for Sick Children, Toronto, Canada
3Department of Pediatric Critical Care, Children's Hospital, London Health Sciences Centre, London, Canada
4Department of Pediatric Critical Care, McMaster Children's Hospital, Hamilton, Canada
5Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
6Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
7Department of Bioethics, Children's Hospital of Eastern Ontario, Ottawa, Canada
8Department of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Canada
The Hospital for Sick Children
Introduction:
As the COVID-19 pandemic unfolded, the need for a pediatric triage framework for the whole of Ontario became evident. Early data pointed to an adult burden of COVID-19; two factors made a pediatric pandemic triage framework critical: 1) pediatric resources may need to be repurposed for adult care, 2) rapid evolution of resource scarcity highlights a need for a framework when a pediatric focused pathogen might occur.
Objective:
To establish a pediatric pandemic triage framework that invokes anticipated mortality, baseline morbidity, and anticipated resource utilization in order to identify those patients who would be excluded or removed from intensive care support.
Methods:
A literature review of adult and pediatric triage plans and consultations with PICU, NICU and bioethics colleagues were undertaken. A utilitarian view (saving the most lives, when not all lives can be saved) was prioritized based on consensus and broad support within the literature, and we initiated an iterative process of expert pediatric critical care consideration for broad categories. Legal and hospital administration provided input. We achieved consensus for reasonableness of the framework from the 4 PICU and 8 NICU stakeholder groups in Ontario. Each group had additional discretionary input from local bioethics, legal, and hospital administrative expertise.
Results:
Two tiers were chosen to reflect any escalation in resource scarcity (Figure 1). Projected use of scarce resources (ventilators, extracorporeal life support) and mortality were major triage factors, since prolonged single-patient use of such resources – even with almost certain survival – could exclude multiple other patients from life-saving therapies. With high survival rates in general PICU/NICU populations, and relatively short anticipated length of stay, most patients would meet inclusion rather than exclusion criteria for ICU services. Thus, we also mapped out a triage algorithm (Figure 2); we established a first-come, first-served allocation to be used in such cases. No PICU/NICU patient subgroups were excluded, including patients with chronic comorbidities. While scoring tools are elusive in pediatric patients, mortality risk (with and without invasive support) is increasingly well understood by pediatric and neonatal critical care experts and allows anticipated survival to be incorporated in the framework. Additionally, we ensured that exclusion would not be predicated upon disability per se, or perceived quality of life, given the wide range of quality of life outcomes enjoyed by children and their families. Importantly, latitude would be required for decisions specific to unique disease processes. Our framework includes a model for triage team composition, including clinical, administrative and Bioethics expertise to reach rapid and transparent consensus decisions, with an appeal process where appropriate.
Conclusion:
Ultimately, pediatric triage during a pandemic is an inherently fraught process; our transparent and accountable framework for such decisions may help mitigate moral distress, and will allow a fair process in the worst-case scenario.
Image 1
Image 2
Clinical Triage Protocol for Major Surge in COVID Pandemic. Ontario Health. March 28, 2020.
Truog RD, Mitchell C, Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic. NEJM. 2020; DOI: 10.1056/NEJMp2005689
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.
Emanuel E, Persaud G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. NEJM. 2020; DOI: 10.1056/NEJMsb2005114
Topic: COVID-19
Kirsch RE1,2, Helmers A1,2, Schwartz S1, Tijssen J3, Yates R4, Moore GP5, Ly L6, Mullen M7, Anderson J2, McCradden M2, Dhanani S8, Gilfoyle E1.
1Department of Critical Care, The Hospital for Sick Children, Toronto, Canada
2Department of Bioethics, The Hospital for Sick Children, Toronto, Canada
3Department of Pediatric Critical Care, Children's Hospital, London Health Sciences Centre, London, Canada
4Department of Pediatric Critical Care, McMaster Children's Hospital, Hamilton, Canada
5Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
6Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
7Department of Bioethics, Children's Hospital of Eastern Ontario, Ottawa, Canada
8Department of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Canada
The Hospital for Sick Children
Introduction:
As the COVID-19 pandemic unfolded, the need for a pediatric triage framework for the whole of Ontario became evident. Early data pointed to an adult burden of COVID-19; two factors made a pediatric pandemic triage framework critical: 1) pediatric resources may need to be repurposed for adult care, 2) rapid evolution of resource scarcity highlights a need for a framework when a pediatric focused pathogen might occur.
Objective:
To establish a pediatric pandemic triage framework that invokes anticipated mortality, baseline morbidity, and anticipated resource utilization in order to identify those patients who would be excluded or removed from intensive care support.
Methods:
A literature review of adult and pediatric triage plans and consultations with PICU, NICU and bioethics colleagues were undertaken. A utilitarian view (saving the most lives, when not all lives can be saved) was prioritized based on consensus and broad support within the literature, and we initiated an iterative process of expert pediatric critical care consideration for broad categories. Legal and hospital administration provided input. We achieved consensus for reasonableness of the framework from the 4 PICU and 8 NICU stakeholder groups in Ontario. Each group had additional discretionary input from local bioethics, legal, and hospital administrative expertise.
Results:
Two tiers were chosen to reflect any escalation in resource scarcity (Figure 1). Projected use of scarce resources (ventilators, extracorporeal life support) and mortality were major triage factors, since prolonged single-patient use of such resources – even with almost certain survival – could exclude multiple other patients from life-saving therapies. With high survival rates in general PICU/NICU populations, and relatively short anticipated length of stay, most patients would meet inclusion rather than exclusion criteria for ICU services. Thus, we also mapped out a triage algorithm (Figure 2); we established a first-come, first-served allocation to be used in such cases. No PICU/NICU patient subgroups were excluded, including patients with chronic comorbidities. While scoring tools are elusive in pediatric patients, mortality risk (with and without invasive support) is increasingly well understood by pediatric and neonatal critical care experts and allows anticipated survival to be incorporated in the framework. Additionally, we ensured that exclusion would not be predicated upon disability per se, or perceived quality of life, given the wide range of quality of life outcomes enjoyed by children and their families. Importantly, latitude would be required for decisions specific to unique disease processes. Our framework includes a model for triage team composition, including clinical, administrative and Bioethics expertise to reach rapid and transparent consensus decisions, with an appeal process where appropriate.
Conclusion:
Ultimately, pediatric triage during a pandemic is an inherently fraught process; our transparent and accountable framework for such decisions may help mitigate moral distress, and will allow a fair process in the worst-case scenario.
Image 1
Image 2
Clinical Triage Protocol for Major Surge in COVID Pandemic. Ontario Health. March 28, 2020.
Truog RD, Mitchell C, Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic. NEJM. 2020; DOI: 10.1056/NEJMp2005689
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.
Emanuel E, Persaud G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. NEJM. 2020; DOI: 10.1056/NEJMsb2005114
ePoster
Topic: COVID-19
Kirsch RE1,2, Helmers A1,2, Schwartz S1, Tijssen J3, Yates R4, Moore GP5, Ly L6, Mullen M7, Anderson J2, McCradden M2, Dhanani S8, Gilfoyle E1.
1Department of Critical Care, The Hospital for Sick Children, Toronto, Canada
2Department of Bioethics, The Hospital for Sick Children, Toronto, Canada
3Department of Pediatric Critical Care, Children's Hospital, London Health Sciences Centre, London, Canada
4Department of Pediatric Critical Care, McMaster Children's Hospital, Hamilton, Canada
5Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
6Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
7Department of Bioethics, Children's Hospital of Eastern Ontario, Ottawa, Canada
8Department of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Canada
The Hospital for Sick Children
Introduction:
As the COVID-19 pandemic unfolded, the need for a pediatric triage framework for the whole of Ontario became evident. Early data pointed to an adult burden of COVID-19; two factors made a pediatric pandemic triage framework critical: 1) pediatric resources may need to be repurposed for adult care, 2) rapid evolution of resource scarcity highlights a need for a framework when a pediatric focused pathogen might occur.
Objective:
To establish a pediatric pandemic triage framework that invokes anticipated mortality, baseline morbidity, and anticipated resource utilization in order to identify those patients who would be excluded or removed from intensive care support.
Methods:
A literature review of adult and pediatric triage plans and consultations with PICU, NICU and bioethics colleagues were undertaken. A utilitarian view (saving the most lives, when not all lives can be saved) was prioritized based on consensus and broad support within the literature, and we initiated an iterative process of expert pediatric critical care consideration for broad categories. Legal and hospital administration provided input. We achieved consensus for reasonableness of the framework from the 4 PICU and 8 NICU stakeholder groups in Ontario. Each group had additional discretionary input from local bioethics, legal, and hospital administrative expertise.
Results:
Two tiers were chosen to reflect any escalation in resource scarcity (Figure 1). Projected use of scarce resources (ventilators, extracorporeal life support) and mortality were major triage factors, since prolonged single-patient use of such resources – even with almost certain survival – could exclude multiple other patients from life-saving therapies. With high survival rates in general PICU/NICU populations, and relatively short anticipated length of stay, most patients would meet inclusion rather than exclusion criteria for ICU services. Thus, we also mapped out a triage algorithm (Figure 2); we established a first-come, first-served allocation to be used in such cases. No PICU/NICU patient subgroups were excluded, including patients with chronic comorbidities. While scoring tools are elusive in pediatric patients, mortality risk (with and without invasive support) is increasingly well understood by pediatric and neonatal critical care experts and allows anticipated survival to be incorporated in the framework. Additionally, we ensured that exclusion would not be predicated upon disability per se, or perceived quality of life, given the wide range of quality of life outcomes enjoyed by children and their families. Importantly, latitude would be required for decisions specific to unique disease processes. Our framework includes a model for triage team composition, including clinical, administrative and Bioethics expertise to reach rapid and transparent consensus decisions, with an appeal process where appropriate.
Conclusion:
Ultimately, pediatric triage during a pandemic is an inherently fraught process; our transparent and accountable framework for such decisions may help mitigate moral distress, and will allow a fair process in the worst-case scenario.
Image 1
Image 2
Clinical Triage Protocol for Major Surge in COVID Pandemic. Ontario Health. March 28, 2020.
Truog RD, Mitchell C, Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic. NEJM. 2020; DOI: 10.1056/NEJMp2005689
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.
Emanuel E, Persaud G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. NEJM. 2020; DOI: 10.1056/NEJMsb2005114
Topic: COVID-19
Kirsch RE1,2, Helmers A1,2, Schwartz S1, Tijssen J3, Yates R4, Moore GP5, Ly L6, Mullen M7, Anderson J2, McCradden M2, Dhanani S8, Gilfoyle E1.
1Department of Critical Care, The Hospital for Sick Children, Toronto, Canada
2Department of Bioethics, The Hospital for Sick Children, Toronto, Canada
3Department of Pediatric Critical Care, Children's Hospital, London Health Sciences Centre, London, Canada
4Department of Pediatric Critical Care, McMaster Children's Hospital, Hamilton, Canada
5Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
6Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
7Department of Bioethics, Children's Hospital of Eastern Ontario, Ottawa, Canada
8Department of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Canada
The Hospital for Sick Children
Introduction:
As the COVID-19 pandemic unfolded, the need for a pediatric triage framework for the whole of Ontario became evident. Early data pointed to an adult burden of COVID-19; two factors made a pediatric pandemic triage framework critical: 1) pediatric resources may need to be repurposed for adult care, 2) rapid evolution of resource scarcity highlights a need for a framework when a pediatric focused pathogen might occur.
Objective:
To establish a pediatric pandemic triage framework that invokes anticipated mortality, baseline morbidity, and anticipated resource utilization in order to identify those patients who would be excluded or removed from intensive care support.
Methods:
A literature review of adult and pediatric triage plans and consultations with PICU, NICU and bioethics colleagues were undertaken. A utilitarian view (saving the most lives, when not all lives can be saved) was prioritized based on consensus and broad support within the literature, and we initiated an iterative process of expert pediatric critical care consideration for broad categories. Legal and hospital administration provided input. We achieved consensus for reasonableness of the framework from the 4 PICU and 8 NICU stakeholder groups in Ontario. Each group had additional discretionary input from local bioethics, legal, and hospital administrative expertise.
Results:
Two tiers were chosen to reflect any escalation in resource scarcity (Figure 1). Projected use of scarce resources (ventilators, extracorporeal life support) and mortality were major triage factors, since prolonged single-patient use of such resources – even with almost certain survival – could exclude multiple other patients from life-saving therapies. With high survival rates in general PICU/NICU populations, and relatively short anticipated length of stay, most patients would meet inclusion rather than exclusion criteria for ICU services. Thus, we also mapped out a triage algorithm (Figure 2); we established a first-come, first-served allocation to be used in such cases. No PICU/NICU patient subgroups were excluded, including patients with chronic comorbidities. While scoring tools are elusive in pediatric patients, mortality risk (with and without invasive support) is increasingly well understood by pediatric and neonatal critical care experts and allows anticipated survival to be incorporated in the framework. Additionally, we ensured that exclusion would not be predicated upon disability per se, or perceived quality of life, given the wide range of quality of life outcomes enjoyed by children and their families. Importantly, latitude would be required for decisions specific to unique disease processes. Our framework includes a model for triage team composition, including clinical, administrative and Bioethics expertise to reach rapid and transparent consensus decisions, with an appeal process where appropriate.
Conclusion:
Ultimately, pediatric triage during a pandemic is an inherently fraught process; our transparent and accountable framework for such decisions may help mitigate moral distress, and will allow a fair process in the worst-case scenario.
Image 1
Image 2
Clinical Triage Protocol for Major Surge in COVID Pandemic. Ontario Health. March 28, 2020.
Truog RD, Mitchell C, Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic. NEJM. 2020; DOI: 10.1056/NEJMp2005689
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.
Emanuel E, Persaud G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. NEJM. 2020; DOI: 10.1056/NEJMsb2005114
COVID-19 and the Creation of an Ontario Pediatric Pandemic Triage Plan
Roxanne Kirsch
Abstract
Discussion Forum (0)
ePoster
Topic: COVID-19
Kirsch RE1,2, Helmers A1,2, Schwartz S1, Tijssen J3, Yates R4, Moore GP5, Ly L6, Mullen M7, Anderson J2, McCradden M2, Dhanani S8, Gilfoyle E1.
1Department of Critical Care, The Hospital for Sick Children, Toronto, Canada
2Department of Bioethics, The Hospital for Sick Children, Toronto, Canada
3Department of Pediatric Critical Care, Children's Hospital, London Health Sciences Centre, London, Canada
4Department of Pediatric Critical Care, McMaster Children's Hospital, Hamilton, Canada
5Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
6Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
7Department of Bioethics, Children's Hospital of Eastern Ontario, Ottawa, Canada
8Department of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Canada
The Hospital for Sick Children
Introduction:
As the COVID-19 pandemic unfolded, the need for a pediatric triage framework for the whole of Ontario became evident. Early data pointed to an adult burden of COVID-19; two factors made a pediatric pandemic triage framework critical: 1) pediatric resources may need to be repurposed for adult care, 2) rapid evolution of resource scarcity highlights a need for a framework when a pediatric focused pathogen might occur.
Objective:
To establish a pediatric pandemic triage framework that invokes anticipated mortality, baseline morbidity, and anticipated resource utilization in order to identify those patients who would be excluded or removed from intensive care support.
Methods:
A literature review of adult and pediatric triage plans and consultations with PICU, NICU and bioethics colleagues were undertaken. A utilitarian view (saving the most lives, when not all lives can be saved) was prioritized based on consensus and broad support within the literature, and we initiated an iterative process of expert pediatric critical care consideration for broad categories. Legal and hospital administration provided input. We achieved consensus for reasonableness of the framework from the 4 PICU and 8 NICU stakeholder groups in Ontario. Each group had additional discretionary input from local bioethics, legal, and hospital administrative expertise.
Results:
Two tiers were chosen to reflect any escalation in resource scarcity (Figure 1). Projected use of scarce resources (ventilators, extracorporeal life support) and mortality were major triage factors, since prolonged single-patient use of such resources – even with almost certain survival – could exclude multiple other patients from life-saving therapies. With high survival rates in general PICU/NICU populations, and relatively short anticipated length of stay, most patients would meet inclusion rather than exclusion criteria for ICU services. Thus, we also mapped out a triage algorithm (Figure 2); we established a first-come, first-served allocation to be used in such cases. No PICU/NICU patient subgroups were excluded, including patients with chronic comorbidities. While scoring tools are elusive in pediatric patients, mortality risk (with and without invasive support) is increasingly well understood by pediatric and neonatal critical care experts and allows anticipated survival to be incorporated in the framework. Additionally, we ensured that exclusion would not be predicated upon disability per se, or perceived quality of life, given the wide range of quality of life outcomes enjoyed by children and their families. Importantly, latitude would be required for decisions specific to unique disease processes. Our framework includes a model for triage team composition, including clinical, administrative and Bioethics expertise to reach rapid and transparent consensus decisions, with an appeal process where appropriate.
Conclusion:
Ultimately, pediatric triage during a pandemic is an inherently fraught process; our transparent and accountable framework for such decisions may help mitigate moral distress, and will allow a fair process in the worst-case scenario.
Image 1
Image 2
Clinical Triage Protocol for Major Surge in COVID Pandemic. Ontario Health. March 28, 2020.
Truog RD, Mitchell C, Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic. NEJM. 2020; DOI: 10.1056/NEJMp2005689
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.
Emanuel E, Persaud G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. NEJM. 2020; DOI: 10.1056/NEJMsb2005114
Topic: COVID-19
Kirsch RE1,2, Helmers A1,2, Schwartz S1, Tijssen J3, Yates R4, Moore GP5, Ly L6, Mullen M7, Anderson J2, McCradden M2, Dhanani S8, Gilfoyle E1.
1Department of Critical Care, The Hospital for Sick Children, Toronto, Canada
2Department of Bioethics, The Hospital for Sick Children, Toronto, Canada
3Department of Pediatric Critical Care, Children's Hospital, London Health Sciences Centre, London, Canada
4Department of Pediatric Critical Care, McMaster Children's Hospital, Hamilton, Canada
5Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
6Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
7Department of Bioethics, Children's Hospital of Eastern Ontario, Ottawa, Canada
8Department of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Canada
The Hospital for Sick Children
Introduction:
As the COVID-19 pandemic unfolded, the need for a pediatric triage framework for the whole of Ontario became evident. Early data pointed to an adult burden of COVID-19; two factors made a pediatric pandemic triage framework critical: 1) pediatric resources may need to be repurposed for adult care, 2) rapid evolution of resource scarcity highlights a need for a framework when a pediatric focused pathogen might occur.
Objective:
To establish a pediatric pandemic triage framework that invokes anticipated mortality, baseline morbidity, and anticipated resource utilization in order to identify those patients who would be excluded or removed from intensive care support.
Methods:
A literature review of adult and pediatric triage plans and consultations with PICU, NICU and bioethics colleagues were undertaken. A utilitarian view (saving the most lives, when not all lives can be saved) was prioritized based on consensus and broad support within the literature, and we initiated an iterative process of expert pediatric critical care consideration for broad categories. Legal and hospital administration provided input. We achieved consensus for reasonableness of the framework from the 4 PICU and 8 NICU stakeholder groups in Ontario. Each group had additional discretionary input from local bioethics, legal, and hospital administrative expertise.
Results:
Two tiers were chosen to reflect any escalation in resource scarcity (Figure 1). Projected use of scarce resources (ventilators, extracorporeal life support) and mortality were major triage factors, since prolonged single-patient use of such resources – even with almost certain survival – could exclude multiple other patients from life-saving therapies. With high survival rates in general PICU/NICU populations, and relatively short anticipated length of stay, most patients would meet inclusion rather than exclusion criteria for ICU services. Thus, we also mapped out a triage algorithm (Figure 2); we established a first-come, first-served allocation to be used in such cases. No PICU/NICU patient subgroups were excluded, including patients with chronic comorbidities. While scoring tools are elusive in pediatric patients, mortality risk (with and without invasive support) is increasingly well understood by pediatric and neonatal critical care experts and allows anticipated survival to be incorporated in the framework. Additionally, we ensured that exclusion would not be predicated upon disability per se, or perceived quality of life, given the wide range of quality of life outcomes enjoyed by children and their families. Importantly, latitude would be required for decisions specific to unique disease processes. Our framework includes a model for triage team composition, including clinical, administrative and Bioethics expertise to reach rapid and transparent consensus decisions, with an appeal process where appropriate.
Conclusion:
Ultimately, pediatric triage during a pandemic is an inherently fraught process; our transparent and accountable framework for such decisions may help mitigate moral distress, and will allow a fair process in the worst-case scenario.
Image 1
Image 2
Clinical Triage Protocol for Major Surge in COVID Pandemic. Ontario Health. March 28, 2020.
Truog RD, Mitchell C, Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic. NEJM. 2020; DOI: 10.1056/NEJMp2005689
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.
Emanuel E, Persaud G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. NEJM. 2020; DOI: 10.1056/NEJMsb2005114
ePoster
Topic: COVID-19
Kirsch RE1,2, Helmers A1,2, Schwartz S1, Tijssen J3, Yates R4, Moore GP5, Ly L6, Mullen M7, Anderson J2, McCradden M2, Dhanani S8, Gilfoyle E1.
1Department of Critical Care, The Hospital for Sick Children, Toronto, Canada
2Department of Bioethics, The Hospital for Sick Children, Toronto, Canada
3Department of Pediatric Critical Care, Children's Hospital, London Health Sciences Centre, London, Canada
4Department of Pediatric Critical Care, McMaster Children's Hospital, Hamilton, Canada
5Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
6Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
7Department of Bioethics, Children's Hospital of Eastern Ontario, Ottawa, Canada
8Department of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Canada
The Hospital for Sick Children
Introduction:
As the COVID-19 pandemic unfolded, the need for a pediatric triage framework for the whole of Ontario became evident. Early data pointed to an adult burden of COVID-19; two factors made a pediatric pandemic triage framework critical: 1) pediatric resources may need to be repurposed for adult care, 2) rapid evolution of resource scarcity highlights a need for a framework when a pediatric focused pathogen might occur.
Objective:
To establish a pediatric pandemic triage framework that invokes anticipated mortality, baseline morbidity, and anticipated resource utilization in order to identify those patients who would be excluded or removed from intensive care support.
Methods:
A literature review of adult and pediatric triage plans and consultations with PICU, NICU and bioethics colleagues were undertaken. A utilitarian view (saving the most lives, when not all lives can be saved) was prioritized based on consensus and broad support within the literature, and we initiated an iterative process of expert pediatric critical care consideration for broad categories. Legal and hospital administration provided input. We achieved consensus for reasonableness of the framework from the 4 PICU and 8 NICU stakeholder groups in Ontario. Each group had additional discretionary input from local bioethics, legal, and hospital administrative expertise.
Results:
Two tiers were chosen to reflect any escalation in resource scarcity (Figure 1). Projected use of scarce resources (ventilators, extracorporeal life support) and mortality were major triage factors, since prolonged single-patient use of such resources – even with almost certain survival – could exclude multiple other patients from life-saving therapies. With high survival rates in general PICU/NICU populations, and relatively short anticipated length of stay, most patients would meet inclusion rather than exclusion criteria for ICU services. Thus, we also mapped out a triage algorithm (Figure 2); we established a first-come, first-served allocation to be used in such cases. No PICU/NICU patient subgroups were excluded, including patients with chronic comorbidities. While scoring tools are elusive in pediatric patients, mortality risk (with and without invasive support) is increasingly well understood by pediatric and neonatal critical care experts and allows anticipated survival to be incorporated in the framework. Additionally, we ensured that exclusion would not be predicated upon disability per se, or perceived quality of life, given the wide range of quality of life outcomes enjoyed by children and their families. Importantly, latitude would be required for decisions specific to unique disease processes. Our framework includes a model for triage team composition, including clinical, administrative and Bioethics expertise to reach rapid and transparent consensus decisions, with an appeal process where appropriate.
Conclusion:
Ultimately, pediatric triage during a pandemic is an inherently fraught process; our transparent and accountable framework for such decisions may help mitigate moral distress, and will allow a fair process in the worst-case scenario.
Image 1
Image 2
Clinical Triage Protocol for Major Surge in COVID Pandemic. Ontario Health. March 28, 2020.
Truog RD, Mitchell C, Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic. NEJM. 2020; DOI: 10.1056/NEJMp2005689
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e61S-74S.
Emanuel E, Persaud G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. NEJM. 2020; DOI: 10.1056/NEJMsb2005114
Topic: COVID-19
Kirsch RE1,2, Helmers A1,2, Schwartz S1, Tijssen J3, Yates R4, Moore GP5, Ly L6, Mullen M7, Anderson J2, McCradden M2, Dhanani S8, Gilfoyle E1.
1Department of Critical Care, The Hospital for Sick Children, Toronto, Canada
2Department of Bioethics, The Hospital for Sick Children, Toronto, Canada
3Department of Pediatric Critical Care, Children's Hospital, London Health Sciences Centre, London, Canada
4Department of Pediatric Critical Care, McMaster Children's Hospital, Hamilton, Canada
5Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
6Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
7Department of Bioethics, Children's Hospital of Eastern Ontario, Ottawa, Canada
8Department of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Canada
The Hospital for Sick Children
Introduction:
As the COVID-19 pandemic unfolded, the need for a pediatric triage framework for the whole of Ontario became evident. Early data pointed to an adult burden of COVID-19; two factors made a pediatric pandemic triage framework critical: 1) pediatric resources may need to be repurposed for adult care, 2) rapid evolution of resource scarcity highlights a need for a framework when a pediatric focused pathogen might occur.
Objective:
To establish a pediatric pandemic triage framework that invokes anticipated mortality, baseline morbidity, and anticipated resource utilization in order to identify those patients who would be excluded or removed from intensive care support.
Methods:
A literature review of adult and pediatric triage plans and consultations with PICU, NICU and bioethics colleagues were undertaken. A utilitarian view (saving the most lives, when not all lives can be saved) was prioritized based on consensus and broad support within the literature, and we initiated an iterative process of expert pediatric critical care consideration for broad categories. Legal and hospital administration provided input. We achieved consensus for reasonableness of the framework from the 4 PICU and 8 NICU stakeholder groups in Ontario. Each group had additional discretionary input from local bioethics, legal, and hospital administrative expertise.
Results:
Two tiers were chosen to reflect any escalation in resource scarcity (Figure 1). Projected use of scarce resources (ventilators, extracorporeal life support) and mortality were major triage factors, since prolonged single-patient use of such resources – even with almost certain survival – could exclude multiple other patients from life-saving therapies. With high survival rates in general PICU/NICU populations, and relatively short anticipated length of stay, most patients would meet inclusion rather than exclusion criteria for ICU services. Thus, we also mapped out a triage algorithm (Figure 2); we established a first-come, first-served allocation to be used in such cases. No PICU/NICU patient subgroups were excluded, including patients with chronic comorbidities. While scoring tools are elusive in pediatric patients, mortality risk (with and without invasive support) is increasingly well understood by pediatric and neonatal critical care experts and allows anticipated survival to be incorporated in the framework. Additionally, we ensured that exclusion would not be predicated upon disability per se, or perceived quality of life, given the wide range of quality of life outcomes enjoyed by children and their families. Importantly, latitude would be required for decisions specific to unique disease processes. Our framework includes a model for triage team composition, including clinical, administrative and Bioethics expertise to reach rapid and transparent consensus decisions, with an appeal process where appropriate.
Conclusion:
Ultimately, pediatric triage during a pandemic is an inherently fraught process; our transparent and accountable framework for such decisions may help mitigate moral distress, and will allow a fair process in the worst-case scenario.
Image 1
Image 2
Clinical Triage Protocol for Major Surge in COVID Pandemic. Ontario Health. March 28, 2020.
Truog RD, Mitchell C, Daley GQ. The Toughest Triage – Allocating Ventilators in a Pandemic. NEJM. 2020; DOI: 10.1056/NEJMp2005689
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